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1 big thing: Everything will be a fight

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Insurers and hospitals came out swinging yesterday against Democrats’ proposal to let people older than 50 buy into Medicare — a reminder that almost any expansion of public health coverage will provoke a battle with the health care industry.

Between the lines: Politically, an age-restricted Medicare buy-in is about as moderate as it gets for Democrats in the age of “Medicare for All.”

  • It is not a proposal for universal coverage, and it’s a far cry from trying to eliminate private insurance. It would be optional, only a relatively small slice of people would have the option, and they would need to pay a monthly premium.

Yes, but: Being on the more moderate end of the political spectrum does not shield you from a fight.

  • Expanding Medicare would hurt hospitals’ bottom lines, because Medicare pays hospitals less than private insurance does.
  • That’s why the Federation of American Hospitals said yesterday that the idea “would harm more Americans than it would help.”
  • The buy-in plan would primarily compete with employer-based health coverage (that’s what people between 50 and 65 are likely to have). And America’s Health Insurance Plans said the idea “is a slippery slope to government-run health care for every American.”

The bottom line: Any proposal that would compete with (never mind eliminate) private coverage, particularly employer coverage, will meet this kind of resistance.

That’s why Medicaid is the public program Democrats and industry can agree to love. Expanded access to Medicaid has rarely been an alternative to commercial insurance — it’s usually an alternative to being uninsured.

  • The uninsured were the primary beneficiaries of the Affordable Care Act’s Medicaid expansion, and the Medicaid buy-in proposals now popping in the states are aimed at the people who are most likely to be foregoing private ACA coverage because of its cost.

 

 

 

I am not a salesman

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I am not a salesman

Abstract: This article looks into the importance of selling in business and the relevance of the development of selling skills to career success regardless of your role in an organization.

Really?  You’re not a salesman or saleswoman or salesperson?  What are you then?  Zig Ziglar and others argue that everyone is in selling whether he or she recognize or acknowledge it or not.  I have come across people that say that they consciously and intentionally do not know anything about selling or that selling is below their station in life.  Some of them have no idea that some of the best-compensated people in society achieve the success they enjoy from being successful in sales.

What is selling anyway?   I would define selling as bringing someone else around to your way of thinking.  The hoped result of the selling process is that the other party will decide to act upon your suggestions and recommendations (closing questions).  Sometimes this results in a sale for value in which goods or services are exchanged. In other cases, you are selling a concept or ideas like a strategy or recommended course of action to a decision maker that must put their reputation and possibly their job on the line by committing to your proposed course of action.

When some people hear the term ‘salesman’ the image that pops up in their mind is the high-pressure wielding scoundrel at the ‘buy here, pay here, Se Habla Español’ used car dealership with the moussed hair, polyester leisure suit, braided leather suspenders, and patent leather platform shoes.   The sales weasel is the offensive stereotype that ‘professionals’ avoid at all costs. However, the argument can be made that the scoundrel has a much easier way of making a living than those of us that make our living by selling ideas, concepts, and strategies into sophisticated organizations.  He is not up against counterparties that in many cases are considerably more experienced, educated, credentialed or intelligent than he is.  More often than not, the reverse is true.

If you would just as soon not be bothered with selling, my suggestion is that you dispense with aspirations of obtaining or staying in a C-Suite role.  What is a C-Suite?  One definition is that it is a marketplace of ideas.  The environment is characterized by continuous, ongoing debate of concepts and strategies to move the organization forward or respond to problems and threats.  If you are not effective in getting your ideas heard, debated and accepted, you might want to start thinking about finding another way to make a living.  If you cannot successfully sell your fair share of ideas in what is usually a very intimidating, competitive and sometimes hostile environment, your perceived value will fall along with the probability of achieving your career ambitions.

What types of selling occur?  Direct selling involves interactions with the intended purpose of an agreement to exchange goods or services for money.  What I will refer to as professional selling is focused on winning in the marketplace of ideas.  In other words, getting decision-makers to take your advice, respond to your counsel or choose a course of action based primarily upon your input. Professional selling is infinitely more difficult because it has a variable that is usually not present in direct selling – politics.  The politics are carried out generally behind the scenes by competitors of yours that could be trusted co-workers that advocate for their ideas behind the scenes or behind your back, without giving you the courtesy or respect of a face-to-face argument.  They use whatever leverage is available to them behind the scenes, under the table, and behind your back to advance their causes, frequently resulting in decisions that do not make rational sense.  Suboptimal results occur because, in the presence of politics, decision making is usually irrational.

For example, I experienced a situation where some physicians were not happy with some of the decisions coming out of the boardroom and the front office.  Do you know how many visits I had from any of the doctors?  The answer is zero!  Instead, they took their grievances directly to members of the board or county commission that humored and engaged them possibly in utter and absolute ignorance of the degree to which this amounted to the active undermining of the leadership team of the organization.  I learned that one board member was accosted in the church vestibule and never made it into the sanctuary to join their family for the service.  Others are caught at their places of work or during unrelated social events.  As we are seeing in our society right now, people that are sufficiently strident about their position will resort to extreme means including violence to have their ideology imposed upon the rest of us.  If you are in a board meeting and something entirely unexpected comes out of left field and derails something that you have put a lot of time and energy into, there is a good chance you are a victim of cowardly, destructive politics.

The stakes of success in a political environment are exponentially higher.  If you are to be successful when you are up against political resistance, your arguments or the effectiveness of your selling must be sufficiently compelling to not only overcome the logical burden of your case but the political forces that may be working against you behind the scenes or maybe more accurately stated, behind your back.  If this is not selling, I don’t know what is.  Most of the time, to one degree or another, your career is potentially on the line when you are selling to your leader or a board of trustees.  Must close selling puts you in an Apollo 13 situation where failure is not an option.  I sold vacuum cleaners in college.  I learned these concepts early on.  In-home vacuum selling can be very intense, high-pressure selling.  That said, selling vacuum cleaners is infinitely more comfortable than surviving in the shark tank that is the C-Suite of most organizations I have experienced.  I guess that’s why good vacuum cleaner salesmen make around $50K and C-Suite roles pay into seven figures.

So, the obvious question is what you should be doing?  My recommendation is that you start dedicating significant time and energy to learning as much as you can about selling.  The quintessential sales trainer is Zig Ziglar. He is one of the best but not the only one.  I would also recommend Harvey Mackay. Both of these guys are retired, but their work is as relevant as ever. Effective selling requires a healthy positive attitude.  There are many excellent motivational speakers. Some of my favorites are Les Brown, Earl Nightingale, Dr. Angela Duckworth, Zig Ziglar, and Ed Foreman.  Don’t overlook some of the incredible ministers that deliver messages of hope and inspiration.  For starters, I recommend Charles Stanley, Johnny Hunt, Robert Schuller, and Joel Osteen.  I have found that the more time I spend listening to these inspiring people, the luckier I become in the marketplace of ideas in a consulting firm, among my compadres, in a hospital C-Suite or down at the local watering hole.

Contact me to discuss any questions or observations you might have about these articles, leadership, transitions or interim services.  I might have an idea or two that might be valuable to you. An observation from my experience is that we need better leadership at every level in organizations. Some of my feedback is coming from people that are demonstrating an interest in advancing their careers, and I am writing content to address those inquiries.

The easiest way to keep abreast of this blog is to become a follower.  You will be notified of all updates as they occur.  To become a follower, click the “Following” bubble that usually appears near the bottom of each web page.

I encourage you to use the comment section at the bottom of each article to provide feedback and stimulate discussion.  I welcome input and feedback that will help me to improve the quality and relevance of this work.

This blog is original work.  I claim copyright of this material with reproduction prohibited without attribution. I note and provide links to supporting documentation for non-original material.  If you choose to link any of my articles, I’d appreciate notification.

 

 

 

‘Outrageous giveaway to Big Pharma’: A political ‘bomb’ over drug prices may threaten NAFTA 2.0

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https://www.japantimes.co.jp/news/2019/02/13/business/outrageous-giveaway-big-pharma-political-bomb-drug-prices-may-threaten-nafta-2-0/#.XGR6YlVKi1s

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 The clash over free trade in North America has long been fought over familiar issues: low-paid Mexican workers. U.S. factories that move jobs south of the border. Canada’s high taxes on imported milk and cheese.

But as Democrats in Congress consider whether to back a revamped regional trade pact being pushed by President Donald Trump, they’re zeroing in on a new point of conflict: drug prices. They contend that the new pact would force Americans to pay more for prescription drugs, and their argument has dimmed the outlook for one of Trump’s signature causes.

The president’s proposed replacement for the 25-year-old North American Free Trade Agreement is meant to win over Democrats by incentivizing factories to hire and expand in the United States. Yet the pact would also give pharmaceutical companies 10 years’ protection from cheaper competition in a category of ultra-expensive drugs called biologics, which are made from living cells.

Shielded from competition, critics warn, the drug companies could charge exorbitant prices for biologics.

“This is an outrageous giveaway to Big Pharma,” Rep. Rosa DeLauro, a Connecticut Democrat, said in an interview. “The government guarantees at least 10 years of market exclusivity for biologic medicine. It’s a monopoly. It’s bad policy.”

The objections of DeLauro and other Democrats suddenly carry greater potency. The need to curb high drug prices has become a rallying cry for voters of all political stripes. Trump himself has joined the outcry. The revamped North America trade deal must be approved by both chambers of Congress, and Democrats have just regained control of the House.

Rep. Earl Blumenauer of Oregon, the new chairman of the House Ways and Means subcommittee on trade, told The Associated Press that “I don’t think candidly that it passes out of my trade subcommittee” with the biologics provision intact.

“The biologics are some of the most expensive drugs on the planet,” Blumenauer said.

Still, the politics of NAFTA 2.0 are tricky for Democrats and not necessarily a sure-fire winner for them.

The original NAFTA, which took effect in 1994, tore down most trade barriers separating the United States, Canada and Mexico. Like Trump, many Democrats blamed NAFTA for encouraging American factories to abandon the United States to capitalize on lower-wage Mexican labor and then to ship goods back into the U.S., duty-free.

Having long vilified NAFTA, Trump demanded a new deal — one far more favorable to the United States and its workers. For more than a year, his top negotiator, Robert Lighthizer, held talks with Canada and Mexico. Lighthizer managed to insert into the new pact provisions designed to appeal to Democrats and their allies in organized labor. For example, 40 percent of cars would eventually have to be made in countries that pay autoworkers at least $16 an hour — that is, in the United States and Canada and not in Mexico — to qualify for duty-free treatment.

The new deal also requires Mexico to encourage independent unions that will bargain for higher wages and better working conditions.

Late last year, the three countries signed their revamped deal, the U.S.-Mexico-Canada Agreement. But it wouldn’t take effect until their three legislatures all approved it. In the meantime, the old NAFTA remains in place.

The question now is: Are Democrats prepared to support a deal that addresses some of their key objections to NAFTA and thereby hand Trump a political victory? Some Democrats have praised the new provisions that address auto wages, though many say they must be strengthened before they’d vote for the USMCA.

Protection for drug companies is another matter. Many Democrats had protested even when the Obama administration negotiated eight years of protection for biologics— from cheap-copycat competitors called “biosimilars” — in a 12-country Pacific Rim trade pact called the Trans-Pacific Partnership, or TPP.

Trump abandoned the TPP in his first week in office. But the pharmaceutical industry is a potent lobby in Washington, and Trump’s negotiators pressed for protection for U.S. biologics in the new North American free trade deal. They ended up granting the drug companies two additional years of protection in the pact.

Top biologics include the anti-inflammatory drug Humira, the cancer fighter Rituxan and Enbrel, which is used to treat rheumatoid arthritis.

The administration and drug companies argue that makers of biologics need time to profit from their creations before biosimilars sweep in, unburdened by the cost of researching and developing the drugs. Otherwise, they contend, the brand-name drug companies would have little incentive to invest in developing new medicines.

They note that a 2015 law authorizing presidents to negotiate trade deals requires American officials to push other countries toward U.S.-level protections for intellectual property such as biologic drugs. (The same law, somewhat contradictorily, directs U.S. negotiators to “promote access to medicines.”)

Supporters also note that existing U.S. law gives makers of biologics 12 years’ protection. So the new pact wouldn’t change the status quo in the United States, though it would force Mexico to expand biologics’ monopoly from five years and Canada from eight years. In fact, supporters of the biologics monopoly argue that the pact might cut prices in the United States because drug companies would no longer face pressure to charge Americans more to compensate for lower prices in Canada and Mexico.

But critics say that expanding biologics’ monopoly in a trade treaty would prevent the United States from ever scaling back the duration to, say, the seven years the Obama administration once proposed.

“By including 10 years in a treaty, we are locking ourselves in to a higher level of monopoly protection for drugs that are already taking in billions of dollars a year,” said Jeffrey Francer, general counsel for the Association for Accessible Medicines, which represents generic drug companies. “The only way for Congress to change it is to back out of the treaty. … Does the United States want to be in violation of its own treaty?”

For Democrats, higher drug prices are shaping up as a powerful political argument against approving the president’s new North American trade deal. In December, Stanley Greenberg, a leading Democratic pollster and strategist, conducted focus groups in Michigan and Wisconsin with Trump voters who weren’t affiliated with the Republican Party. Some had previously voted for Barack Obama. Others called themselves political independents. They’re the kinds of voters Democrats hope to attract in 2020.

Greenberg said he was “shocked” by the intensity of their hostility to drug companies — and to the idea that a trade pact would shield those companies from competition.

“It was like throwing a bomb into the focus group,” said Greenberg, who is married to DeLauro. He said the voters’ consensus view was essentially: “The president was supposed to go and renegotiate (NAFTA) so that it worked for American workers. But it must be that these lobbyists are working behind the scenes” to sneak in special-interest provisions.

That perception gives Democrats reason to reject the new pact as the 2020 election approaches.

“Democrats have no incentive to do this,” said Philip Levy, a senior fellow at the Chicago Council on Global Affairs and a White House economist under President George W. Bush. “Before you know it, the presidential election season is going to be upon us.”

U.S. trade rules are designed to force Congress to give trade agreements an up-or-down vote — no nitpicking allowed. Still, there are ways to bypass those restrictions. Congressional Democrats could, for example, push the administration to negotiate so-called side letters with Canada and Mexico to address their concerns. President Bill Clinton did this with the original NAFTA.

“Lighthizer and his team are very creative,” said Blumenauer, chair of the House trade subcommittee. “This is something that can be handled.”

 

 

 

Health Insurance Coverage Eight Years After the ACA

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https://www.commonwealthfund.org/publications/issue-briefs/2019/feb/health-insurance-coverage-eight-years-after-aca

Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured

What does health insurance coverage look like for Americans today, more than eight years after the Affordable Care Act’s passage? In this brief, we present findings from the Commonwealth Fund’s latest Biennial Health Insurance Survey to assess the extent and quality of coverage for U.S. working-age adults. Conducted since 2001, the survey uses three measures to gauge the adequacy of people’s coverage:

  • whether or not they have insurance
  • if they have insurance, whether they have experienced a gap in their coverage in the prior year
  • whether high out-of-pocket health care costs and deductibles are causing them to be underinsured, despite having continuous coverage throughout the year.

As the findings highlighted below show, the greatest deterioration in the quality and comprehensiveness of coverage has occurred among people in employer plans. More than half of Americans under age 65 — about 158 million people — get their health insurance through an employer, while about one-quarter either have a plan purchased through the individual insurance market or are enrolled in Medicaid.1Although the ACA has expanded and improved coverage options for people without access to a job-based health plan, the law largely left the employer market alone.2

Survey Highlights

  • Today, 45 percent of U.S. adults ages 19 to 64 are inadequately insured — nearly the same as in 2010 — though important shifts have taken place.
  • Compared to 2010, many fewer adults are uninsured today, and the duration of coverage gaps people experience has shortened significantly.
  • Despite actions by the Trump administration and Congress to weaken the ACA, the adult uninsured rate was 12.4 percent in 2018 in this survey, statistically unchanged from the last time we fielded the survey in 2016.
  • More people who have coverage are underinsured now than in 2010, with the greatest increase occurring among those in employer plans.
  • People who are underinsured or spend any time uninsured report cost-related problems getting care and difficulty paying medical bills at at higher rates than those with continuous, adequate coverage.
  • Federal and state governments could enact policies to extend the ACA’s health coverage gains and improve the cost protection provided by individual-market and employer plans.

The 2018 Commonwealth Fund Biennial Heath Insurance Survey included a nationally representative sample of 4,225 adults ages 19 to 64. SSRS conducted the telephone survey between June 27 and November 11, 2018.3 (See “How We Conducted This Study” for more detail.)

WHO IS UNDERINSURED?

In this analysis, we use a measure of underinsurance that accounts for an insured adult’s reported out-of-pocket costs over the course of a year, not including insurance premiums, as well as his or her plan deductible. (The measure was first used in the Commonwealth Fund’s 2003 Biennial Health Insurance Survey.*) These actual expenditures and the potential risk of expenditures, as represented by the deductible, are then compared with household income. Specifically, we consider people who are insured all year to be underinsured if:

  • their out-of-pocket costs, excluding premiums, over the prior 12 months are equal to 10 percent or more of household income; or
  • their out-of-pocket costs, excluding premiums, over the prior 12 months are equal to 5 percent or more of household income for individuals living under 200 percent of the federal poverty level ($24,120 for an individual or $49,200 for a family of four); or
  • their deductible constitutes 5 percent or more of household income.

The out-of-pocket cost component of the measure is only triggered if a person uses his or her plan to obtain health care. The deductible component provides an indicator of the financial protection the plan offers and the risk of incurring costs before someone gets health care. The definition does not include other dimensions of someone’s health plan that might leave them potentially exposed to costs, such as copayments or uncovered services. It therefore provides a conservative measure of underinsurance in the United States.

Compared to 2010, when the ACA became law, fewer people today are uninsured, but more people are underinsured. Of the 194 million U.S. adults ages 19 to 64 in 2018, an estimated 87 million, or 45 percent, were inadequately insured (see Tables 1 and 2).

Despite actions by the Trump administration and Congress to weaken the ACA, our survey found no statistically significant change in the adult uninsured rate by late 2018 compared to 2016 (Table 3). This finding is consistent with recent federal surveys, but other private surveys (including other Commonwealth Fund surveys) have found small increases in uninsured rates since 2016 (see “Changes in U.S. Uninsured Rates Since 2013”).

While there has been no change since 2010, statistically speaking, in the proportion of people who are insured now but have experienced a recent time without coverage, these reported gaps are of much shorter duration on average than they were before the ACA. In 2018, 61 percent of people who reported a coverage gap said it has lasted for six months or less, compared to 31 percent who said they had been uninsured for a year or longer. This is nearly a reverse of what it was like in 2012, two years before the ACA’s major coverage expansions. In that year, 57 percent of adults with a coverage gap reported it was for a year or longer, while one-third said it was a shorter gap.

There also has been some improvement in long-term uninsured rates. Among adults who were uninsured at the time of the survey, 54 percent reported they had been without coverage for more than two years, down from 72 percent before the ACA coverage expansions went into effect. The share of those who had been uninsured for six months or less climbed to 20 percent, nearly double the rate prior to the coverage expansions.

Of people who were insured continuously throughout 2018, an estimated 44 million were underinsured because of high out-of-pocket costs and deductibles (Table 1). This is up from an estimated 29 million in 2010 (data not shown). The most likely to be underinsured are people who buy plans on their own through the individual market including the marketplaces. However, the greatest growth in the number of underinsured adults is occurring among those in employer health plans.

WHY ARE INSURED AMERICANS SPENDING SO MUCH OF THEIR INCOME ON HEALTH CARE COSTS?

Several factors may be contributing to high underinsured rates among adults in individual market plans and rising rates in employer plans:

  1. Although the Affordable Care Act’s reforms to the individual market have provided consumers with greater protection against health care costs, many moderate-income Americans have not seen gains. The ACA’s essential health benefits package, cost-sharing reductions for lower- income families, and out-of-pocket cost limits have helped make health care more affordable for millions of Americans. But while the cost-sharing reductions have been particularly important in lowering deductibles and copayments for people with incomes under 250 percent of the poverty level (about $62,000 for a family of four), about half of people who purchase marketplace plans, and all of those buying plans directly from insurance companies, do not have them.4
  2. The bans against insurers excluding people from coverage because of a preexisting condition and rating based on health status have meant that individuals with greater health needs, and thus higher costs, are now able to get health insurance in the individual market. Not surprisingly, the survey data show that people with individual market coverage are somewhat more likely to have health problems than they were in 2010, which means they also have higher costs.
  3. While plans in the employer market historically have provided greater cost protection than plans in the individual market, businesses have tried to hold down premium growth by asking workers to shoulder an increasing share of health costs, particularly in the form of higher deductibles.5 While the ACA’s employer mandate imposed a minimum coverage requirement on large companies, the requirement amounts to just 60 percent of typical person’s overall costs. This leaves the potential for high plan deductibles and copayments.
  4. Growth in Americans’ incomes has not kept pace with growth in health care costs. Even when health costs rise more slowly, they can take an increasingly larger bite out of incomes.

It is well documented that people who gained coverage under the ACA’s expansions have better access to health care as a result.6 This has led to overall improvement in health care access, as indicated by multiple surveys.7 In 2014, the year the ACA’s major coverage expansions went into effect, the share of adults in our survey who said that cost prevented them from getting health care that they needed, such as prescription medication, dropped significantly (Table 4). But there has been no significant improvement since then.

The lack of continued improvement in overall access to care nationally reflects the fact that coverage gains have plateaued, and underinsured rates have climbed. People who experience any time uninsured are more likely than any other group to delay getting care because of cost (Table 5). And among people with coverage all year, those who were underinsured reported cost-related delays in getting care at nearly double the rate of those who were not underinsured.

There was modest but significant improvement following the ACA’s coverage expansions in the proportion of all U.S. adults who reported having difficulty paying their medical bills or said they were paying off medical debt over time (Table 4). Federal surveys have found similar improvements.8 However, those gains have stalled.

Inadequate insurance coverage leaves people exposed to high health care costs, and these expenses can quickly turn into medical debt. More than half of uninsured adults and insured adults who have had a coverage gap reported that they had had problems paying medical bills or were paying off medical debt over time (Table 6). Among people who had continuous insurance coverage, the rate of medical bill and debt problems is nearly twice as high for the underinsured as it is for people who are not underinsured.

Having continuous coverage makes a significant difference in whether people have a regular source of care, get timely preventive care, or receive recommended cancer screenings. Adults with coverage gaps or those who were uninsured when they responded to the survey were the least likely to have gotten preventive care and cancer screenings in the recommended time frame.

Being underinsured, however, does not seem to reduce the likelihood of having a usual source of care or receiving timely preventive care or cancer screens — provided a person has continuous coverage. This is likely because the ACA requires insurers and employers to cover recommended preventive care and cancer screens without cost-sharing. Even prior to the ACA, a majority of employer plans provided predeductible coverage of preventive services.9

Conclusion and Policy Implications

U.S. working-age adults are significantly more likely to have health insurance since the ACA became law in 2010. But the improvement in uninsured rates has stalled. In addition, more people have health plans that fail to adequately protect them from health care costs, with the fastest deterioration in cost protection occurring in the employer market. The ACA made only minor changes to employer plans, and the erosion in cost protection has taken a bite out of the progress made in Americans’ health coverage since the law’s enactment.

Both the federal government and the states, however, have the ability to extend the law’s coverage gains and improve the cost protection of both individual-market and employer plans. Here is a short list of policy options:

  • Expand Medicaid without restrictions. The 2018 midterm elections moved as many as five states closer to joining the 32 states that, along with the District of Columbia, have expanded eligibility for Medicaid under the ACA.10 As many as 300,000 people may ultimately gain coverage as a result.11 But, encouraged by the Trump administration, several states are imposing work requirements on people eligible for Medicaid — a move that could reverse these coverage gains. So far, the U.S. Department of Health and Human Services (HHS) has approved similar work-requirement waivers in seven states and is considering applications from at least seven more. Arkansas imposed a work requirement last June, and, to date, more than 18,000 adults have lost their insurance coverage as a result.
  • Ban or place limits on short-term health plans and other insurance that doesn’t comply with the ACA. The Trump administration loosened regulations on short-term plans that don’t comply with the ACA, potentially leaving people who enroll in them exposed to high costs and insurance fraud. These plans also will draw healthier people out of the marketplaces, increasing premiums for those who remain and federal costs of premium subsidies. Twenty-three states have banned or placed limits on short-term insurance policies. Some lawmakers have proposed a federal ban.
  • Reinsurance, either state or federal. The ACA’s reinsurance program was effective in lowering marketplace premiums. After it expired in 2017, several states implemented their own reinsurance programs.12  Alaska’s program reduced premiums by 20 percent in 2018. These lower costs particularly help people whose incomes are too high to qualify for ACA premium tax credits. More states are seeking federal approval to run programs in their states. Several congressional bills have proposed a federal reinsurance program.
  • Reinstate outreach and navigator funding for the 2020 open-enrollment period. The administration has nearly eliminated funding for advertising and assistance to help people enroll in marketplace plans.13 Research has found that both activities are effective in increasing enrollment.14 Some lawmakers have proposed reinstatingthis funding.
  • Lift the 400-percent-of-poverty cap on eligibility for marketplace tax credits. This action would help people with income exceeding $100,000 (for a family of four) better afford marketplace plans. The tax credits work by capping the amount people pay toward their premiums at 9.86 percent. Lifting the cap has a built in phase out: as income rises, fewer people qualify, since premiums consume an increasingly smaller share of incomes. RAND researchers estimate that this policy change would increase enrollment by 2 million and lower marketplace premiums by as much as 4 percent as healthier people enroll. It would cost the federal government an estimated $10 billion annually.15 Legislation has been introduced to lift the cap.
  • Make premium contributions for individual market plans fully tax deductible. People who are self-employed are already allowed to do this.16
  • Fix the so-called family coverage glitch. People with employer premium expenses that exceed 9.86 percent of their income are eligible for marketplace subsidies, which trigger a federal tax penalty for their employers. There’s a catch: this provision applies only to single-person policies, leaving many middle-income families caught in the “family coverage glitch.” Congress could lower many families’ premiums by pegging unaffordable coverage in employer plans to family policies instead of single policies.17

REDUCE COVERAGE GAPS

  • Inform the public about their options. People who lose coverage during the year are eligible for special enrollment periods for ACA marketplace coverage. Those eligible for Medicaid can sign up at any time. But research indicates that many people who lose employer coverage do not use these options.18 The federal government, the states, and employers could increase awareness of insurance options outside the open-enrollment periods through advertising and education.
  • Reduce churn in Medicaid. Research shows that over a two-year period, one-quarter of Medicaid beneficiaries leave the program and become uninsured.19 Many do so because of administrative barriers.20 By imposing work requirements, as some states are doing, this involuntary disenrollment is likely to get worse. To help people stay continuously covered, the federal government and the states could consider simplifying and streamlining the enrollment and reenrollment processes.
  • Extend the marketplace open-enrollment period. The current open-enrollment period lasts just 45 days. Six states that run their own marketplaces have longer periods, some by as much as an additional 45 days. Other states, as well as the federal marketplace, could extend their enrollment periods as well.

IMPROVE INDIVIDUAL-MARKET PLANS’ COST PROTECTIONS

  • Fund and extend the cost-sharing reduction subsidies. The Trump administration eliminated payments to insurers for offering plans with lower deductibles and copayments. Insurers, which by law must still offer reduced-cost plans, are making up the lost revenue by raising premiums. But this fix, while benefiting enrollees who are eligible for premium tax credits, has distorted both insurer pricing and consumer choice.21 In addition, it is unknown whether the administration’s support for the fix will continue in the future, creating uncertainty for insurers.22 Congress could reinstate the payments to insurers and consider making the plans available to people with higher earnings.
  • Increase the number of services excluded from the deductible.Most plans sold in the individual market exclude certain services from the deductible, such as primary care visits and certain prescriptions.23As the survey data suggest, these types of exclusions appear to be important in ensuring access to preventive care among people who have coverage but are underinsured. In 2016, HHS provided a standardized plan option for insurers that excluded eight health services — including mental health and substance-use disorder outpatient visits and most prescription drugs — from the deductible at the silver and gold level.24 The Trump administration eliminated the option in 2018. Congress could make these exceptions mandatory for all plans.

IMPROVE EMPLOYER PLANS’ COST PROTECTIONS

  • Increase the ACA’s minimum level of coverage. Under the ACA, people in employer plans may become eligible for marketplace tax credits if the actuarial value of their plan is less than 60 percent, meaning that under 60 percent of health care costs, on average, are covered. Congress could increase this to the 70 percent standard of silver-level marketplace plans, or even higher.
  • Require deductible exclusions. Congress could require employers to increase the number of services that are covered before someone meets their deductible. Most employer plans exclude at least some services from their deductibles.25 Congress could specify a minimum set of exclusions for employer plans that might resemble the standardized-choice options that once existed for ACA plans.
  • Refundable tax credits for high out-of-pocket costs. Congress could make refundable tax credits available to help insured Americans pay for qualifying out-of-pocket costs that exceed a certain percentage of their income.26
  • Protect consumers from surprise medical bills. Several states have passed laws that protect patients and their families from unexpected medical bills, generally from out-of-network providers.27A bipartisan group of U.S. senators has proposed federal legislation to protect consumers, including people enrolled in employer and individual-market plans.

Health care costs are primarily what’s driving growth in premiums across all health insurance markets. Employers and insurers have kept premiums down by increasing consumers’ deductibles and other cost-sharing, which in turn is making more people underinsured. This means that policy options like the ones we’ve highlighted above will need to be paired with efforts to slow medical spending. These could include changing how health care is organized and providers are paid to achieve greater value for health care dollars and better health outcomes.28 The government also could tackle rising prescription drug costs29 and use antitrust laws to combat the growing concentration of insurer and provider markets.30

 

 

Since the ACA, Fewer Adults Are Uninsured, but More Are Underinsured

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https://www.commonwealthfund.org/chart/2019/aca-fewer-adults-are-uninsured-more-are-underinsured

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Hospital Mergers Improve Health? Evidence Shows the Opposite

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Hospital Mergers Improve Health? Evidence Shows the Opposite

Image result for hospital market power

Many things affect your health. Genetics. Lifestyle. Modern medicine. The environment in which you live and work.

But although we rarely consider it, the degree of competition among health care organizations does so as well.

Markets for both hospitals and physicians have become more concentrated in recent years. Although higher prices are the consequences most often discussed, such consolidation can also result in worse health care. Studies show that rates of mortality and of major health setbacks grow when competition falls.

This runs counter to claims some in the health care industry have made in favor of mergers. By harnessing economies of scale and scope, they’ve argued, larger organizations can offer better care at lower costs.

In one recent example, two Texas health systems — Baylor Scott & White, and Memorial Hermann Health System — sought to merge, forming a 68-hospital system. The systems have since abandoned the plan, but not before Jim Hinton, Baylor Scott & White’s chief executive, told The Wall Street Journal that “the end, the more important end, is to improve care.”

Yet Martin Gaynor, a Carnegie Mellon University economist who been an author of several reviews exploring the consequences of hospital consolidation, said that “evidence from three decades of hospital mergers does not support the claim that consolidation improves quality.” This is especially true when government constrains prices, as is the case for Medicare in the United States and Britain’s National Health Service.

“When prices are set by the government, hospitals don’t compete on price; they compete on quality,” Mr. Gaynor said. But this doesn’t happen in markets that are highly consolidated.

In 2006, the National Health Service introduced a policy that increased competition among hospitals. When recommending hospital care, it required general practitioners to provide patients with five options, as well as quality data for each. Because hospital payments are fixed by the government — whichever hospital a patient chooses gets the payment for care provided to that patient — hospitals ended up competing on quality.

Mr. Gaynor was an author of a study showing that consequences of this policy included shorter hospital stays and lower mortality. According to the study, for every decrease of 10 percentage points in hospital market concentration, 30-day mortality for heart attacks fell nearly 3 percent.

Another study found that hospital competition in the N.H.S. decreased heart attack mortality, and several studies of Medicare also found that hospital competition results in lower rates of mortality from heart attacks and pneumonia.

Another piece of evidence in the competition-quality connection comes from other types of health care providers, including doctors. Recently, investigators from the Federal Trade Commission examined what happens when cardiologists team up into larger groups. The study, published in Health Services Research, focused on the health care outcomes of about two million Medicare beneficiaries who had been treated for hypertension, for a cardiac ailment or for a heart attack from 2005 to 2012.

The study found that when cardiology markets are more concentrated, these kinds of patients are more likely to have heart attacks, visit the emergency department, be readmitted to the hospital or die. These effects of market concentration are large.

To illustrate, consider a cardiology market with five practices in which one becomes more dominant — going from just below a 40 percent market share to a 60 percent market share (with the rest of the market split equally across the other four practices). The study found that the chance of having a heart attack would go up 5 to 7 percent as the largest cardiology practice became more dominant. The chance of visiting the emergency department, being readmitted to the hospital or dying would go up similarly.

The study also found that greater market concentration led to higher spending. And a different study of family doctors in England found that quality and patient satisfaction increased with competition.

For many goods and services, Americans are comfortable with the idea that competition leads to lower prices and better quality. But we often think of health care as different — that it somehow shouldn’t be “market based.”

What the research shows, though, is that there are lots of ways markets can function, with more or less government involvement. Even when the government is highly involved, as is the case with the British National Health Service or American Medicare, competition is a valuable tool that can drive health care toward greater value.

 

 

Patient Financial Experience the New Focus for Revenue Cycle Tech

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https://revcycleintelligence.com/features/patient-financial-experience-the-new-focus-for-revenue-cycle-tech?eid=CXTEL000000093912&elqCampaignId=8479&elqTrackId=be91ef7e45814e448e63f5f449863c07&elq=c0883462d36f46f1919e194284b0fcd0&elqaid=8937&elqat=1&elqCampaignId=8479

Facing healthcare consumerism and high deductibles, providers are seeking revenue cycle technology to deliver a high-quality patient financial experience.

Hospitals and practices have traditionally relied on public and private payers to cover the bulk of patient charges and costs for their services. Everything from their revenue cycle technologies to billing workflows has been tailored to create cleaner claims, reduce denials, and collect payer reimbursement.

But in an environment of record spending and changing attitudes towards purchasing and payment, payers are starting to shift more financial responsibility to their consumers. Nearly 21 million Americans had a high-deductible health plan or health savings account in 2017, and AHIP experts anticipate enrollment in high-deductible plans to continue climbing.

Increases in patient out-of-pocket spending are driving individuals to become more discerning healthcare consumers who demand more value for the medical services they receive. Plans and policymakers argue that the rise in healthcare consumerism will ultimately result in lower cost, higher quality care.

In the meantime, however, high-deductible health plans and other increases in out-of-pocket spending are presenting challenges to providers who are not used to this new player: the patient as a payer.

Three-quarters of providers report that they are seeing a noticeable upward trend in what patients must pay out of pocket.   At hospitals, total revenue attributable to patient balances after insurance rose 88 percent from 2012 to 2017.

While payers have been steadily shifting the financial responsibility to consumers, providers have yet to adapt their workflows and systems to collect revenue from this new source while delivering a satisfactory experience to consumers.

For example, nearly all 900 healthcare financial executives recently surveyed by HIMSS Analytics said their organizations still use paper-based billing and collection strategies – despite the fact that the same survey revealed more than half of patients prefer electronic billing methods.

Patients in the survey even said they were more likely to pay their medical bills if they had the option to do so online.

In light of these statistics, providers are facing the difficult task of transforming their manual patient collection processes to address this changing, consumer-focused trend.

“What we’ve seen historically has been that the revenue cycle has been not as well funded or not as strategically prioritized for healthcare delivery networks. A lot of the decision making has been either reactive or more short-term oriented,” Joe Polaris, Senior Vice President of Product and Technology at the health IT company R1 RCM, recently told RevCycleIntelligence.com.

“But we’re starting to see more of a long-term strategic vision coming together for their revenue cycles,” he added. “Organizations understand they need to make transformative change in light of some of the challenges that are only growing in the market, especially the need to be consumer-friendly.”

Revenue cycle technologies that cater to the patient financial experience are part of that transformative change, added Matt Hawkins, the CEO of Waystar, the newly combined revenue cycle management company formed by ZirMed and Navicure.

“Innovators are beginning, more so than ever, to treat the patient as a consumer,” he said. “A lot of health systems are demanding or embracing services or technologies that get them closer to patients from the earliest interaction point.”

The demand for technologies that cater to the patient financial experience is on the rise. And providers could face significant financial losses and patient retention problems if they fail to adapt to healthcare consumerism.

Becoming a patient-centered entity that can collect what it’s owed without alienating its consumers is a significant challenge, experts agree.  But embracing a handful of high-impact strategies could help to ensure that both patients and their providers complete the payment process feeling satisfied.

PRICE TRANSPARENCY LAYS THE FOUNDATION FOR PATIENT FINANCIAL EXPERIENCE

“Consumerism” may be a popular buzzword in the healthcare industry, but providers still have a long way to go before their patients can accurately compare their clinical journeys to their retail experiences.

For one thing, patients often agree to services or procedures with no clear idea of what they will ultimately cost.

Providers rarely offer prices or price estimates to patients prior to service delivery. In fact, the percentage of hospitals that are not able to give consumers price estimates actually increased from 14 percent in 2012 to 44 percent in 2018, a recent JAMA Internal Medicine study revealed.

With patients expecting the ability to plan their expenses, providers are looking to implement new revenue cycle technologies that can deliver accurate cost estimates and boost overall healthcare price transparency.

“How do we give patients shoppable experiences, so they can find out the cost of an MRI?” asked Christy Martin, Senior Vice President of Product Management at Optum360. “In their local care market, where is the best place to go in terms of both quality and cost? Then, if they go to a certain location, what are they expected to pay based on their insurance coverage? What would the out-of-pocket costs be at this point in the year?”

Informing consumers of their patient financial responsibility before the point-of-service is critical for providers seeking to improve the patient financial experience.

“In the immediate future, one of the things that we can unlock using technology is an understanding upfront about what the payment responsibility will be, and have that help inform all of the things that happen subsequent to presenting that to the patient,” Hawkins said.

Providing price estimates up front helped one health system in Oklahoma increase point-of-service collections by $17 million in seven years.

The Consumer Priceline tool at INTEGRIS Health is a database of charges for most procedures and services. The health system also promises to deliver written price quotes to consumers within two days if the service is not already included in the database.

INTEGRIS may be seeing significant patient collection improvements using price estimates, but providers should be aware that databases like the Consumer Priceline tool require a wealth of historical financial data.

“In the immediate future, one of the things that we can unlock using technology is an understanding upfront about what the payment responsibility will be.”

Merely posting chargemaster prices for common services and procedures is not necessarily helpful for patients. Giving consumers information about their patient financial responsibility and out-of-pocket costs is supposed to prevent sticker shock. Yet chargemaster prices are primarily used to start negotiations with payers, and the numbers can seem exorbitant to consumers.

“Chargemaster prices serve only as a starting point; adjustments to these prices are routinely made for contractual discounts that are negotiated with or set by third-party payers. Few patients actually pay the chargemaster price,” the Healthcare Financial Management Association (HMFA) explained to policymakers in May 2018.

Despite reservations about chargemaster prices, CMS recently required hospitals to publish a list of their standard charges online. And providers are scrambling to understand how to present the information in a meaningful way to consumers.

About 92 percent of providers in a recent poll said they were concerned about the new hospital price transparency requirement, and the majority also expressed concerns about how the public would perceive their standard charges.

Now more than ever, revenue cycle technologies that aggregate and analyze information on what patients actually pay will be critical for health systems.

UNIFYING THE PATIENT FINANCIAL EXPERIENCE

Healthcare is nothing like going grocery shopping. Not only do consumers not have access to prices, but the funding mechanism for medical services is also vastly different from a traditional retail experience.

Unlike what happens during a retail transaction, healthcare consumers rarely pay providers directly for services or procedures rendered. Instead, healthcare consumers use insurance plans, health savings accounts, and a wide range of other funding mechanisms to eventually pay providers after a service is delivered. They may also receive several bills and benefit documents from providers and insurers before receiving the final bill listing their financial responsibility.

As patients become more responsible for their healthcare spend, the onus is on providers to simplify the patient financial experience if they want to boost collections and save their bottom line.

Delivering a navigable and consistent financial experience is key to making the most of the newly consumer-driven environment, Polaris advised providers.

“The patient wants to have a clear and transparent journey through the healthcare system, and that’s much more challenging when they have to navigate different departments on different systems, asking for the same data over and over again, never coordinating, and never communicating a holistic end-to-end experience,” he said.

Integrated and seamless revenue cycle technologies aim to deliver a consistent patient financial experience by simplifying medical bills and bringing all providers in a practice, hospital, or health system under the same billing brand.

For example, a multi-specialty physician group in central Texas boosted patient collections by 24 percent and reduced the amount of patient cash sitting in A/R from 14 to two percent in one year by unifying the patient financial experience across their organization.

“Even though we were one clinic with 60 providers, our collection process treated every healthcare encounter separately,” explained Abilene Diagnostic Clinics CFO Andrew Kouba, CPA. “Patients were receiving bills for each physician they saw, which allowed them to pick and choose which bills to pay. When you get four statements and you think you got one experience, you’re confused as a patient.”

Consolidating all of Abilene’s providers under one billing system helped the group to deliver a consistent patient financial experience, which in turn simplified the payment process for consumers.

Revenue cycle departments are finding that end-to-end systems or interoperable bolt-on solutions are worth the investment. The integrated technologies allow healthcare organizations to guide the patient through the financial experience.

But to truly advance the patient financial experience, revenue cycle technology experts agreed that clinical and financial data integration is also vital.

“Being able to leverage the clinical and billing data to provide a better patient experience all the way around is a key capability,” Martin of Optum360 stated.

“While hospitals are certainly focused on providing high-quality care, there’s also this focus on how they can improve the overall patient financial experience to reduce the confusion, complexity, and lack of understanding around patient responsibility. Health systems are looking to provide ease of doing business to address patient responsibility and reduce patient bad debt.”

Revenue cycle technologies that can leverage both clinical and financial data are crucial to transforming the patient experience into a consumer-friendly encounter. Understanding the whole patient can help providers offer a consistent experience from the front office to the billing department.

SELF-SERVICE AS THE ULTIMATE PATIENT FINANCIAL EXPERIENCE GOAL

Price transparency tools and integrated revenue cycle technologies lay the groundwork for a consistent, intuitive patient financial experience. But revenue cycle technology vendors are also observing an increased interest in self-service portals and kiosks for the ultimate retail-like experience.

The disjointed, manual processes involved in the patient financial experience have not been convenient for consumers. Patients often have to interact with a call center or sit down with a staff member to complete basic tasks like scheduling, filling out insurance forms, or paying a medical bill, Polaris explained. In other industries, these tasks have already been replaced by mobile apps or automated systems.

“With digital self-service, we automate tasks like they do in the airline industry,” he said. “We let the patient book an appointment right on their mobile phone, get all the paperwork, fill out the forms they need, and check in at a kiosk.”

“Automation takes repetitive tasks that are frankly not patient- or consumer-friendly out of the process and makes the whole healthcare experience much more satisfying,” he stressed.

Self-service portals and kiosks have the potential to truly transform the patient financial experience into a more convenient, navigable journey. But healthcare organizations would need to invest in large amounts of revenue cycle automation to achieve this goal, Polaris acknowledged.

“Automation takes a lot of forms,” he explained. “There’s always been robotics, user emulation, and basic automation to complete individual tasks. But very few organizations have driven automation of entire processes, and that’s where we’re seeing more investment in transformative automation.”

Healthcare consumers have already voiced their support for more self-service options and more automation. A recent survey of over 500 individuals showed that in addition to offering more payment options and sending simpler bills, expanding access to self-service tools was a top suggestion for improving the patient financial experience.

“Automation takes repetitive tasks that are frankly not patient- or consumer-friendly out of the process and makes the whole healthcare experience much more satisfying.”

Providers are also expressing interest in implementing the relatively new technology in the revenue cycle space. Kouba from Abilene Diagnostic Clinic in Texas said he wanted to create a type of Disney FastPass for the patient financial experience.

“We want to simplify the process from pre-registration through bill collection and try to automate that similar to Disney’s FastPass,” Kouba stated. “Disney is one of the best experiences of all time and when you go there, they want you to interact with the people, all their products, and just enjoy yourselves. The last thing Disney wants you to think of is the terrible lines.”

“If we can remove the pain points and strive to ease that front piece, the patient will be focused on a friendly conversation when they walk in the door with the person that can answer questions, rather than being pestered to pull out their wallet.”

However, Kouba is not convinced that full automation will take over the healthcare industry any time soon.

As much as adopting retail-style approaches can improve the patient financial journey, providers must still ensure their technologies and processes work for them, too.

For example, Kouba decided that self-service technology that automates scheduling is not ideal for Abilene.

“In our group, most of our physicians like to follow their patients to the hospital, so the difficult piece with self-scheduling, especially from the provider’s side, is their schedules depend on what their rounds look like for the day. It’s very difficult to get them to commit to blocks of time,” he continued.

Self-service and automated tools may still be maturing in the revenue cycle technology space. But providers still have the option to improve the patient financial experience through systems that estimate patient financial responsibility and unify the billing experience.

And providers should be looking to the revenue cycle technology market for help. The rise of patient financial responsibility has been steady. Deductibles and out-of-pocket costs have been growing, particularly since healthcare spending growth rates rapidly accelerate.

Implementing the right tools for their patients and their providers will be key to empowering patients to choose the highest value care while ensuring providers get paid for it.

 

 

 

 

Clinical Documentation and Coding Top Revenue Cycle Vulnerability

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Image shows clinical documentation and coding is the top area at risk of lost or decreased revenue, according to most hospital leaders.

Hospitals are concerned their clinical documentation and coding processes are resulting in lost or decreased revenue, a new survey shows.

Hospital leaders are concerned that their organization’s clinical documentation and coding processes are vulnerable to errors that could result in lost or decreased revenue, according to a recent survey.

Consulting firm and technology vendor BESLER recently partnered with HIMSS Media to identify the greatest industry challenges and potential opportunities for revenue cycle improvement. They surveyed over 100 leaders within finance, revenue cycle, reimbursement, and health information management (HIM) departments at hospitals and acute-care facilities in October 2018.

The recently released survey results showed that 84 percent of respondents believe clinical documentation and coding are high or medium revenue cycle risk.

Hospital finance leaders were the most adamant that clinical documentation and coding presented significant revenue cycle challenges. Almost one-half of finance leaders chose clinical documentation and coding as their greatest revenue cycle vulnerability.

Although, the area was considered high or medium risk by over one-third of revenue cycle, reimbursement, and HIM leaders as well.

Clinical documentation and coding are creating revenue cycle vulnerabilities because solutions are not optimized for the diagnosis-related group (DRG) payment system, respondents shared. Only about one-third of hospital leaders said DRG optimization is a solved problem. In other words, the majority of hospital leaders (68 percent) do not think their solutions are equipped to manage DRG coding.

The DRG payment system has been around for over three decades. And major payers, including Medicare, use the payment system to determine lump-sum payments for hospitals that treat specific diagnoses.

While the payment system is not new, it is constantly evolving. Payers are attempting to get more specific about diagnoses to ensure hospitals are paid accurately for treating patients with certain conditions. The introduction of ICD-10 in 2015 is a prime example of how the industry has changed the DRG payment system.

But DRG changes are not ideal for providers. Hospitals find it difficult to follow and comply with constant DRG changes, and as a result, DRG coding accuracy has decreased. The report stated that the national benchmark for DRG assignment fell from 95 percent under ICD-9 to 72 percent in 2018.

Revenue cycle solutions, however, are optimized for inpatient coding and audits. Approximately 72 percent of respondents felt their technology is optimized for inpatient coding.

The survey also uncovered that respondents thought the accuracy of inpatient coding at their organizations was about the same as the industry benchmark.

Additionally, the majority of respondents (72 percent) agreed that their revenue cycle solutions are optimized for outpatient coding.

Opportunities to improve revenue cycle management technology remain. And poor coding integrity could result in the top two challenges hospitals face: claim denials (49 percent of respondents) and inaccurate reimbursements (47 percent of respondents).

Image shows claim denials and inaccurate reimbursements are the top two revenue cycle challenges, according to most hospital leaders.

Source: BESLER and HIMSS Media

However, hospitals and health systems face significant obstacles with improving their mid-revenue cycle processes, including DRG coding and documentation. Chief among the challenges is a lack of budget. Nearly one-half of hospital leaders (49 percent) said budget constraints prevented their organization from improving DRG coding and documentation.

Nearly the same percentage of leaders also felt return on investment (ROI) was an obstacle. Forty-eight percent of respondents said difficulty proving ROI from investment stopped their organization from executing DRG optimization efforts.

Other obstacles to improving the mid-revenue cycle included:

  • Competing projects (45 percent)
  • Lack of staff/headcount to manage improvement efforts (38 percent)
  • Lack of familiarly with solutions to address challenges (34 percent)
  • Existing solutions already widely entrenched or accepted (32 percent)
  • Overcoming internal perceptions that there is no need for improvement (30 percent)

Respondents identified a variety of challenges, but the survey also found a potential solution for hospitals and acute-care facilities. The survey showed that nearly half of respondents (47 percent) have created a revenue integrity program, which ensures organizations are being fully compliant with coding and billing practices while also achieving operational efficiency and legitimate reimbursement.

That means about 53 percent of hospitals still haven’t implemented a revenue integrity program.

About three-quarters of hospitals with revenue integrity programs reported improvements in net collections, increases in gross revenue capture, and/or reduction in compliance risk.